RN Care Coordinator

• Completes and documents a discharge planning assessment on those patients identified by the designated screening process or upon request.Reassess the patient as appropriate and update the plan accordingly.
• Facilitates the development of a multidisciplinary discharge plan engaging other relevant health team members the patient and/or patient representative and post acute care providers in accordance with the patients clinical or psychosocial needs choices and available resources.
• Oversees and evaluates the implementation of the discharge plan.
• Collaborates with the multidisciplinary team to ensure progression of care and appropriate utilization of inpatient resources using established evidence based guidelines/criteria.
• Collaborates with the healthcare team and post-acute service providers to ensure timely and smooth transitions to the most appropriate type and setting of post-acute services based upon patients clinical needs.
• Identifies risk for readmission and implements interventions to mitigate those risks for at least a 30-day period.
• Responsible for delivery of appropriate patient notifications and related documentation
• Responsible for patient education and advocacy.
• Participates in performance improvement teams and programs as necessary.
• Demonstrates behavior that aligns with the Mission and Core Values of the Organization.
• Responsible for completing required education within established timeframes.
• Adheres to all hospital policies standards of practice and Federal or State regulations pertaining to their practice.
• Performs other duties as assigned including utilization review as necessary.

Required

• Graduate of an accredited school of nursing.
• Minimum two (2) years of acute hospital clinical experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience.
• RN license in the state(s) covered is required.
• BLS required within 3 months of hiring if located within hospital